2017年 · 第37卷第05期

Pancreatic cancer accounts for 85% to 95% of all pancreatic malignancies, with a poor prognosis, and is the fourth leading cause of cancer-related death. One of the main causes of poor prognosis in pancreatic cancer is the difficulty of early diagnosis. The most common symptoms of pancreatic cancer (abdominal pain, weight loss, anorexia and weakness, etc.) are non-specific, and there is a lack of effective screening tools for patients with early asymptomatic pancreatic cancer. Although pancreatic cancer combined with pancreatitis is seen accidentally in clinical work, it has been recognized and reported for a long time. Pancreatic cancer complicated by pancreatitis is usually clinically non-specific and overlapping, resulting in delayed diagnosis and delayed treatment. For pancreatic cancer in the background of pancreatitis, the difficulty of initial diagnosis is not only due to the lack of clear clinical manifestations and laboratory findings, but also related to overlapping imaging signs and difficulties in surgical exploration. From the perspective of pathophysiology of pancreatic cancer complicated with pancreatitis, the progress of imaging examination methods in pancreatic cancer complicated with pancreatitis is described.

In 1961, French scholar Sarles first reported a special type of pancreatitis-chronic sclerosing pancreatitis, which has clinical manifestations of mild abdominal pain, obstructive jaundice and hyperimmunoglobulinemia. Since Japanese scholar Yoshida first put forward the concept of autoimmune pancreatitis (AIP) in 1995, people's cognition of AIP has made great progress. Although its etiology is currently unknown, it is gradually recognized that AIP is a unique type of pancreatitis that may be associated with autoimmunity. As a special type of chronic pancreatitis, AIP has been reported in the literature that its incidence rate is about 0.82/1 million in the oriental population, accounting for 2.5% of patients with chronic pancreatitis; In North America, pancreatic duct adenocarcinoma (PDAC) was diagnosed preoperatively, while AIP was confirmed by histopathology in 5% to 6%^[1]。

pancreatic neuroendocrine neoplasm (PNEN) is a neuroendocrine neoplasm (NEN) that mainly occurs in the pancreas and upper small intestine. WHO updated the classification system for gastro-entro-pancreatic neuroendocrine neoplasm (GEP-NEN) in 2010 based on tumor differentiation and grade. The system classifies these tumors according to cell proliferation index Ki-67 or mitotic index into: ① highly differentiated (grade 1 or 2) neuroendocrine tumor (NET), ② poorly differentiated (grade 3) neuroendocrine carcinoma (NEC), ③ mixed adenoneuroendocrine carcinoma (MANEC), ④ site-specific and function-specific NEN. PNEN was classified into functional and non-functional tumors based on clinical presentation. Functional tumors are accompanied by clinical syndromes caused by abnormal hormone secretion, including insulinoma, gastrinoma, vasoactive intestinal peptide tumor (VIPoma or VIP tumor), glucagonoma, somatostatinoma, and other rare tumors. Non-functional tumors (or inactive, clinically quiescent, or non-syndromic) are not associated with a distinct hormone syndrome, but immunohistochemical reactions in serum or tissue sections still show elevated hormone levels. PNEN is mostly located in the pancreas, but can also occur in the duodenum, stomach, lymph nodes, ovaries and other parts. Tumors vary in size, with maximum diameters ranging from a few millimeters to 10 cm, and functional tumors are usually small. Large tumors are more aggressive, and can be manifested as calcification, local invasion, early invasion of the portal vein and liver metastasis. Tumors can be single or multiple. Insulinoma is common as single and benign; Gastrinoma is multiple and malignant, often accompanied by multiple endocrine neoplasms type I (multiple endocrine neoplasia type 1, MEN 1); Non-functional tumors are more common in malignancy.

intestinal tuberculosis (intestinal tuberculosis) is a chronic specific infection caused by Mycobacterium tuberculosis invading the intestine, and it is more common in the ileocecal region^[1]。 Developing countries such as India and China are high incidence areas of tuberculosis, and intestinal tuberculosis is a common extrapulmonary tuberculosis^[2]In recent years, the incidence of tuberculosis has been gradually increasing. At present, computer tomography enterography (CTE) has become the primary examination method for small intestine diseases^[3]。 Traditional X-ray enterography, as a supplement to CTE, can dynamically observe small intestinal peristalsis and better show mucosal lesions. The principle of magnetic resonance enterography (MRE) is the same as that of CTE, and the advantages of non-invasive, non-radiation, high resolution of soft tissue contrast, multi-faceted imaging, and safety of contrast agent are helpful to the popularization of small intestine MRE, especially as the first choice for small intestine examination in children^[4]。

Under ordinary gastroscopy, it is usually easier to identify the lesions with obvious bulge or depression of gastric mucosa, while the flat gastric mucosa lesions only show superficial bulge, depression or mucosal color change under ordinary white light, which is a special type of gastric mucosal lesions that is easy to miss diagnosis. In this study, the gastroscopic findings and pathological data of 194 patients with flat gastric mucosa lesions were analyzed in order to strengthen the understanding of flat gastric mucosa lesions and improve the detection and diagnosis rate of early gastric cancer and precancerous lesions.

extra-hepatic portal vein obstruction (EHPVO) has previously been classified as non-cirrhotic portal vein thrombosis, but it has only been widely recognized in recent years. Its most serious complication is variceal bleeding^[1,2]。 At present, although transjugular intrahepatic portosystemic stent-shunt (TIPS) has become the recommended treatment for cirrhotic portal hypertension^[1,2,3]However, its use in the treatment of EHPVO complicated by variceal bleeding has only been sporadically reported^[3,4,5,6]。 In addition, TIPS complications such as hepatic encephalopathy and stent dysfunction also make people have safety concerns when applying TIPS. This study retrospectively analyzed the clinical data of 49 patients with EHPVO complicated by variceal bleeding treated with TIPS, in order to provide further guidance for clinical treatment.

spontaneous bacterial peritonitis (SBP) is one of the serious complications after liver cirrhosis, and its incidence is 10% ~30%^[1]。 With the development of medical technology and the use of antibiotics, the mortality rate of bacterial peritonitis after liver cirrhosis is decreasing year by year. However, for patients without timely treatment, the mortality rate is still as high as 40% ~50% after one year^[2]。 Early and accurate diagnosis can help medical staff take timely and effective treatment, thus significantly improving the prognosis of bacterial peritonitis after cirrhosis. At present, the diagnosis of SBP after liver cirrhosis mainly depends on the clinical manifestations of patients, ascites WBC count in auxiliary examinations and ascites bacterial culture. However, most patients with liver cirrhosis have low immunity, and do not have typical peritonitis symptoms such as abdominal pain, muscle tension and systemic poisoning in the early stage. The sensitivity of ascites WBC count is low, and it is influenced by the subjective factors of the examiner, while ascites bacterial culture is limited by low positive rate and longer culture time^[2]There is still a lack of rapid and accurate diagnostic indexes for SBP after liver cirrhosis. soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) is a member of the immunoglobulin superfamily^[3]All kinds of immune cell subsets can be expressed rapidly and in large quantities during acute bacterial infection. Both human and animal studies have confirmed that monitoring of serum sTREM-1 levels in peripheral blood can diagnose sepsis early^[4,5,6]。 This study aimed to analyze the level of sTREM-1 in 113 patients with cirrhosis and ascites, and to explore its value in early diagnosis of SBP after cirrhosis.

Colonoscopy is an intuitive and effective method for diagnosing colorectal diseases^[1]。 Improving the detection rate of colorectal polyps is crucial for the prevention of colorectal cancer^[2]。 However, in actual clinical work, the time and difficulty of colonoscopy operation are often increased due to intestinal spasm, which reduces the detection rate of polyps, and even some operations cannot be completed successfully. The study found that 2.4% of colonoscopies could not complete the examination due to pain, and 20.7% refused to be examined again due to fear^[3]。 This study aims to study the effects of prophylactic use of pinavirium bromide before colonoscopy, including alone, combination, and different time periods, on the completion rate of colonoscopy, time to enter the scope, abdominal pain and polyp detection rate, so as to provide a basis for the appropriate use of pinavirium bromide in colonoscopy patients.

Esophageal hemangioma is a kind of benign tumor derived from mesenchymal tissue, which is relatively rare in clinic^[1]。 Patients often lack typical clinical symptoms and are at risk of potential rupture and bleeding. Traditional therapeutic methods are mainly regular follow-up, surgical procedure, endoscopic ligation and sclerosing agent injection. With the widespread application of endoscopic ultrasound, the relationship between tumor and wall level, tumor image and echo characteristics can be clearly revealed, which can assist in the diagnosis of hemangioma and guide the selection of treatment methods^[2]。 In terms of treatment, endoscopic submucosal dissection (ESD) improves the complete resection rate of submucosal tumors^[3]However, there are few reports on the treatment of esophageal hemangioma. The purpose of this study was to explore the application value of endoscopic ultrasound and ESD in the clinical diagnosis and treatment of esophageal hemangioma.

endoscopic retrograde cholangiopancreatography (ERCP) can diagnose common bile duct stones, benign and malignant bile duct obstruction, pancreatic space occupation and other pancreaticobiliary diseases by displaying the pancreaticobiliary duct. Hyperamylasemia and acute pancreatitis are common complications after ERCP. The incidence rate ranges from 1% to 40%, and most of them are about 5%^[1]。 Although pancreatitis after ERCP is mostly mild, 10% of patients still develop severe acute pancreatitis, which is life-threatening.

The small intestine accounts for about 3/4 of the total length of the digestive tract. Because of the wide distribution of small intestine area, its tumor pathogenesis is hidden, and it lacks typical symptoms and signs in early clinical stage, and lacks effective examination methods, so it is easy to be ignored in clinical practice, resulting in misdiagnosis and mistreatment. The medical records of a patient with jejunal adenocarcinoma with imaging manifestations similar to lymphoma admitted to Ruijin Hospital affiliated to Shanghai Jiaotong University School of Medicine were retrospectively analyzed, and the diagnosis and treatment were discussed.

Example 1The 56-year-old female was seen in the First Affiliated Hospital of Zhejiang University School of Medicine in May 2014 due to repeated upper abdominal discomfort for more than 3 years. The patient developed upper abdominal discomfort more than 3 years ago, which was obvious after eating. He had dull upper abdominal pain with dysphagia, fatigue, easy fatigue, occasional nausea and vomiting. He was not paid attention to it and did not see a doctor. Two months ago, the patient felt worse upper abdominal discomfort and dysphagia than before, so he went to a local hospital. Gastroscopy showed a huge ulcer in the duodenal bulb, and pathological biopsy of the gastric antrum showed that inflammatory reaction was considered. After treatment with acid production and stomach protection, the patient's symptoms were not significantly relieved, so he was referred to the First Hospital of Zhejiang University School of Medicine for further treatment. Gastroscopy revealed a huge ulcer in the duodenal bulb (Figure 1)。 Pathological examination of gastroscopic biopsy showed abnormal proliferation of duodenal B lymphocytes, which was in line with diffuse large B cell lymphoma (non-germinal center type); Immunohistochemical examination showed positive results for CD3, CD20, CD79a and CD5, and negative results for CD30 (Ki-1), CD21 and cytokeratin. Upper abdominal enhanced CT examination showed that the intestinal wall at the gastroduodenal junction was thickened, and ulcer-shaped necrosis could be seen inside, which should be considered for malignant mass occupation, seeFigure 2。 Bone marrow puncture examination showed that the hyperplasia of bone marrow hematopoietic tissue was slightly lower with morbid hematopoiesis. positron emission computed tomography (PET) -CT showed that the intestinal wall at the gastroduodenal junction was thickened, and the metabolism of fludeoxyglucose (FDG) was abnormally increased. Combined with the medical history, it was consistent with the metabolic changes of lymphoma. The patient started chemotherapy with monoclonal antibody to rituximid, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) in June 2014. After treatment, the patient suffered from obvious nausea and vomiting, and improved after antiemetic and gastric protection treatment. Subsequently, the patient has been undergoing chemotherapy at the local hospital under the R-CHOP regimen for a total of 9 courses. After the end of chemotherapy, the abdominal CT plain scan + enhancement did not reveal significant abnormalities. The patient's gastroscopy in March 2015 revealed duodenal ulcer (Figure 3), improved compared with the previous, and multiple deep pathological biopsies suggested that inflammatory reactions should be considered.

UC is a chronic colorectal inflammatory reaction of unknown etiology and is a type of IBD. In recent years, with the change of people's living habits and diet structure, the incidence of UC in China has shown a rapid upward trend. As the course of UC becomes longer and longer, the carcinogenesis of UC has attracted increasing clinical attention. Although ulcerative colitis related colorectal cancer (UCRCC) accounts for only 1% to 2% of all colon cancers, about 15% of UC patients die from UCRCC^[1]。 The pathogenesis of UCRCC is still unclear, and the important role played by intestinal flora in UCRCC has attracted increasing attention. This paper introduces the important role of intestinal flora in the carcinogenesis of UC and the research progress of probiotics in inhibiting UC carcinogenesis.

IBS is a chronic intestinal disease with recurrent abdominal pain or abdominal discomfort accompanied by changes in defecation habits and/or fecal characteristics as the main clinical features. It is a neurological, immune, endocrine and psychological related disease, and belongs to functional intestinal disease. IBD, including UC and CD, is a chronic nonspecific inflammatory intestinal disease with unclear etiology. It is mainly related to autoimmune disorders, and environmental and genetic heterogeneity are involved in its pathogenesis. It is an organic intestinal disease. In general, IBS and IBD belong to two different diseases. In recent years, some studies have shown that there is low-grade inflammatory reaction in the intestinal mucosa of some patients with IBS, and this inflammatory reaction may play an important role in the pathogenesis of IBS^[1]； On the other hand, IBD patients in the prodromal or remission stage may also exhibit IBS-like symptoms^[2]This type of IBD and IBS may be confused with each other. This type of IBD shows IBS-like symptoms, and IBS has a low-degree inflammatory reaction in the intestinal mucosa, which blurs the boundary between IBS and IBD. Therefore, some scholars have proposed a new bio-psychological-social medical model for IBD and IBS^[3]。 In order to better understand IBS and IBD in clinical practice, the clinical diagnosis, treatment and prognosis of IBS and IBD are described.

IBD is a kind of intestinal disease characterized by abnormal inflammatory response. Its etiology and pathogenesis are still unclear. It may be due to intestinal microbial infection or stimulation of physical and chemical factors (such as certain foods and drugs), coupled with individual genetic susceptibility and other factors, which cause excessive activation of intestinal mucosal immune response, leading to the occurrence and development of IBD^[1]。 IBD mainly includes UC and CD. The main difference between UC and CD is that the onset sites of UC are mainly in the colon and rectum, while CD can affect the whole digestive tract^[2]。 The study found that there are two new types of Th in the lymphoid germinal center: follicular helper T cell (Tfh) and follicular regulatorry T cell (Tfr). They were localized in lymphoid follicles to differentiate and proliferate^[3]。 These two types of cells have received extensive attention in the study of IBD.